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D D Trunkey

Publications and source records attributed to D D Trunkey.

At least 73 records · Page 4Linked to original sources
PubMed1988

Trauma systems. Current status--future challenges.

The national status of regional trauma system development was evaluated by a survey sent to all state emergency medical services directors and state chairpersons of the American College of Surgeons Committee on Trauma. Eight essential components of a regional trauma system based on criteria set forth by the American College of Surgeons were listed. Only two states were found to have all components and statewide coverage. Nineteen states and the District of Columbia lacked one or more components of a regional trauma system. The remaining 29 states had yet to initiate the process of trauma center designation. In response to these shortcomings, an attempt was made to define the barriers to trauma system implementation and a step-by-step process was outlined for the development, management, and analysis of a comprehensive system of trauma care.

Economics, Hospital↗
PubMed1988

A time for decisions.

Explore the source record for details and available documents.

Emergency Medical Services↗
PubMed1988

CT scanning in acute abdominal injuries.

Computed tomography has become an important adjunct in the evaluation of the patient with blunt abdominal trauma. It provides quantitative information about hemoperitoneum as well as qualitative information about the source of hemoperitoneum. CT scanning also evaluates the retroperitoneal organs and retroperitoneal hematoma more accurately than any other available imaging technique. Like any other diagnostic tool, the CT scan must not be overused or abused. This technique should be applied only to stable patients and only in institutions with up-to-date equipment, a committed radiology and surgery staff, and appropriate monitoring equipment in the CT suite. If proper technique is used, then high-quality scans can be obtained which, if interpreted by experienced personnel in the light of the clinical findings, can improve our management of selected trauma patients.

Abdominal Injuries↗
PubMed1988

Variables affecting outcome in blunt chest trauma: flail chest vs. pulmonary contusion.

We reviewed 144 consecutive patients with flail chest and/or pulmonary contusion between 1979 and 1984. The purpose was to analyze the factors adversely affecting morbidity and mortality. There were 97 males and 47 females, with an average age of 40 years +/- 18 S.D. (range, 2-83). Seventy-five per cent of the injuries were caused by motor vehicle accidents, with the remainder due to falls (17%), cardiopulmonary resuscitation (4%), altercations (2%), or falling objects (2%). The Injury Severity Score (ISS) averaged 32 +/- 14 S.D. in all survivors versus 60 +/- 14 S.D. in those who died. Eighty-three patients (58%) required mechanical ventilation. Thirty-six patients died (25%). Isolated pulmonary contusion or flail chest had a mortality of 16% each. However, the mortality more than doubled when there was a combined pulmonary contusion and flail chest (42%). More than half of all deaths were directly attributed to central nervous system injuries with another third due to massive hemorrhage. Factors that were associated with a higher morbidity and mortality included severe associated thoracic injuries, a high ISS, the presence of shock, falls from heights, and the combination of pulmonary contusion and flail chest.

Adolescent↗
PubMed1987

Endoscopic sclerotherapy versus portacaval shunt in patients with severe cirrhosis and acute variceal hemorrhage. Long-term follow-up.

In a continuation of a trial for which preliminary results were reported in the Journal two years ago, a total of 64 patients with Child Class C cirrhosis and variceal hemorrhage requiring six or more units of blood were randomly assigned to receive either a portacaval shunt (32 patients) or endoscopic sclerotherapy (32 patients). The duration of initial hospitalization and the total amount of blood transfused during hospitalization were significantly less in the patients receiving sclerotherapy (P less than 0.001). There was no difference in short-term survival (50 percent of the sclerotherapy group were discharged alive, as compared with 44 percent of the shunt-surgery group). Both groups were followed for a mean of 530 days after randomization. Rebleeding from varices, the duration of rehospitalization for hemorrhage, and transfusions received after discharge were all significantly greater in the sclerotherapy group (P less than 0.001). Forty percent of the sclerotherapy-treated patients discharged alive (7 of 16 patients) ultimately required surgical treatment for bleeding varices, despite a mean of 6.1 treatment sessions. Health care costs and long-term survival did not differ significantly between the groups (P greater than 0.05). We conclude that although endoscopic sclerotherapy is as good as surgical shunting for the acute management of variceal hemorrhage in poor-risk patients with massive bleeding, sclerotherapy-treated patients in whom varices are not obliterated and bleeding continues should be considered for elective shunt surgery.

Adult↗
PubMed1987

Torso trauma.

This monograph represents an overview of torso trauma. The torso should be viewed as a single unit and injuries may affect the thoracic and abdominal viscera. My approach to the various injuries is pragmatic and usually fairly aggressive. The purpose is to reduce complications and missed injuries and it applies equally well to the surgeon whose practice is extensive or to the surgeon who treats only occasional injuries.

Abdominal Injuries↗
PubMed1987

Computed tomography in the diagnosis of blunt intestinal and mesenteric injuries.

Twenty-four patients with signs on computed tomography (CT) of mesenteric or intestinal injury were treated over a 5-year period (1980-1984). All patients were the victims of blunt abdominal trauma. Nine patients with CT evidence of mesenteric or bowel hematomas were observed without adverse outcome. Fifteen were operatively explored, with 14 having injuries similar to the findings on the preoperative CT scans. In the group that had surgery, either thickened bowel or free intraperitoneal fluid (blood or less dense fluid) or both were present in all but one patient. Extraluminal air (three cases) or Gastrografin (Squibb) (one case) were absolute indications for surgery, as were bowel wall or mesenteric hematomas accompanied by substantial amounts of intraperitoneal fluid. The patient's history, physical examination, and initial laboratory values are important in proper selection of patients for CT evaluation. We feel that CT appears to offer certain definite advantages over peritoneal lavage in evaluation of bowel and mesenteric injuries and can reliably help to distinguish the injuries that require surgical repair from those that can be safely monitored and observed.

Abdominal Injuries↗
PubMed1987

Colostomy closure after colon injury: a low-morbidity procedure.

One justification for expanding the indications for primary repair of colonic injuries is the high morbidity classically associated with colostomy closure. Our impression that this morbidity is overstated prompted us to review our experience with closure of colostomies constructed for treatment of colon trauma for the 5-year period 1979-1984. During this period 75 colostomies created for treatment of colorectal injuries were closed. Complications were frequent after colostomy creation, but few could be attributed to the colostomy. Following colostomy closure, however, complications were infrequent (5%) and generally minor. If morbidity of colostomy closure is cited as a factor justifying expanded indications for primary repair of colon injuries, current morbidity rates should be borne in mind.

Adult↗
PubMed1987

Burns in the elderly.

The records of 327 burn patients over age 65 show that flame burns were the most common causative agent and that more than 70 percent of all burns occurred in the home. Despite improved treatment, mortality from burns remains unacceptably high among the elderly. Future efforts must be directed toward the prevention of these injuries, especially those sustained in the home.

Accidents, Home↗
PubMed1986

Management of the patient with hemorrhaging esophageal varices.

Bleeding from esophageal varices remains a difficult clinical problem, carrying a high likelihood both of rebleeding and of mortality. The initial approach requires adequate but not overly vigorous volume replacement with blood and other fluids. Once the patient is resuscitated, upper gastrointestinal endoscopy should be performed to establish the source of bleeding. Both endoscopic variceal sclerotherapy and balloon tamponade appear to be effective in achieving temporary control of acute ongoing hemorrhage from esophageal varices. The value of intravenous vasopressin remains controversial. Rebleeding can be prevented in most patients by shunt surgery. However, surgery carries both considerable early morbidity and mortality (related mainly to the severity of the underlying liver disease) and substantial longer-term morbidity and mortality from hepatic encephalopathy and liver failure. The role of pharmacologic agents (eg, propranolol) intended to prevent variceal hemorrhage by reducing portal pressure remains to be established. At present, we recommend use of endoscopic variceal sclerotherapy for the control of active variceal bleeding, with employment of balloon tamponade and intravenous vasopressin if sclerotherapy is successful. Emergency shunt surgery should be reserved only for those patients whose bleeding cannot be controlled by these other means. For prevention of rebleeding in Child class C patients, we attempt to obliterate the varices by repeated endoscopic sclerotherapy. Patients who have two to three episodes of rebleeding despite this approach are considered for shunt surgery. For better-risk patients who do not have ascites, which is difficult to control, we are currently recommending a distal splenorenal shunt. Alternatively, repeated endoscopic variceal sclerotherapy is used for these better-risk patients (Child class A or B) in some centers, with shunt surgery reserved for patients who continue to rebleed. Which approach to preventing rebleeding in the better-risk patient is more effective, as well as the role of pharmacologic therapy with propranolol or other agents, remains to be settled by well-controlled randomized clinical trials.

Airway Obstruction↗
PubMed1986

The Trauma Score as a triage tool in the prehospital setting.

Implementation of a regional trauma care system requires a field triage tool that identifies the severely injured patient and transports him to a trauma center, while preserving the flow of minimally injured patients to community hospitals. We prospectively tested the Trauma Score (TS) as a field triage tool and evaluated its accuracy against that of the Injury Severity Score (ISS), calculated after the patients' injuries were fully defined. During an 18-month period, 1106 patients admitted to the trauma center at San Francisco General Hospital had a TS determined in the field (TS1) and on arrival at the emergency department. A TS1 of 14 or less defined a subgroup of 222 patients in whom 93% of the deaths occurred. Using an ISS of 20 or more as an indicator of life-threatening injury, we determined the predictive value of TS1. There were 66 false-negatives (ISS, greater than or equal to 20; TS1, 15 or 16) and 107 false-positives (ISS, less than 20; TS1, less than or equal to 14). Using a prehospital TS of 14 or less as an indicator of serious injury, only 20% of a major urban trauma population would qualify for diversion to a trauma center.

California↗
PubMed1986

Mortality from ruptured abdominal aortic aneurysms. A comparison of two series.

Series of ruptured abdominal aortic aneurysms from a municipal teaching hospital and from a group of private surgeons practicing at four community hospitals were compared for hemodynamic status and time to operation, as well as mortality. The overall mortality rate was 61 percent for the municipal hospital series and 32 percent for the community hospital series, which was significantly different (p = 0.003). The municipal hospital series had a significantly greater number of patients in shock before operation, as well as a greater number of patients transported directly to the operating room. The community hospital series had a significantly greater number of patients with a more than 6 hour delay in diagnosis and delays in surgical exploration. When those patients in shock who were brought directly to the operating room were compared, there was no statistical difference between the two series. Further reviews of ruptured abdominal aortic aneurysms should attempt to identify groups of patients by their hemodynamic status when evaluating treatment.

Aged↗
PubMed1986

Critical care as an integral part of trauma care.

There appears to be reasonable evidence to support the concept of trauma centers, as well as ICUs for the critical care management of the seriously injured trauma patient. For optimal care of such patients, there must be effective delivery of such critical care. Despite some concerns as to who should provide such care to trauma patients, as well as all other patients, there is little debate over the goal of such treatment--that is, optimal care of these seriously injured patients. With this goal in mind, each institution must design a system that provides this care. In most instances, this requires participation between trauma surgeons and critical care specialists, as well as trauma and critical care services. With proper leadership and systems to ensure effective communication between such services, these goals can be achieved. Important secondary goals, in education and research, can also be achieved by such methods. Rather than further fractionate the care of patients, who frequently need 24-hour physician coverage and involvement of people with many different specialty areas of knowledge, it is crucial that an effective, cooperative system be designed for each institution that provides this care.

Critical Care↗
PubMed1985

Myocardial dysfunction in septic shock.

Myocardial depression is a major but poorly understood component of septic shock. This study investigates the morphologic and biochemical abnormalities associated with septic shock. Myocardial cells are incubated in normal and septic plasma in a nutrient-, oxygen-, pH-, electrolyte-, and temperature-controlled environment. Cells and media are tested for basal- and epinephrine-stimulated cyclic adenosine monophosphate (cAMP), lactic dehydrogenase (LDH), and creatine kinase. Electron microscopic studies are done at the end of incubation. Septic LDH and creatine kinase levels in the media are increased substantially, and septic cAMP levels are reduced significantly. Septic cells beat irregularly and arrest along with exhibiting abnormal electron microscopic structure. Septic myocardial dysfunction occurs independently of previously postulated causes that are controlled for in this experiment and therefore may be due to endogenously produced or accumulated toxic factor(s).

Animals↗
PubMed1985

Selective nonoperative management of blunt liver injury using computed tomography.

Computed tomographic (CT) scans are used to evaluate victims of blunt trauma for abdominal injury when reasons for immediate laparotomy are not present. Twenty-four patients whose CT scans showed liver injuries that were small parenchymal lacerations or intrahepatic hematomas were managed without laparotomy. Intra-abdominal blood was absent or estimated to be less than 250 mL in volume. None of the patients were in shock; six patients required transfusions, none for acute abdominal bleeding. None of these patients subsequently required laparotomy or showed hepatobiliary problems at a follow-up examination less than one year later. Five follow-up scans showed varying degrees of resolution. Two patients died of severe head injury, but the liver injury did not contribute to the cause of death. Other patients with more severe blunt liver injury who were treated nonoperatively developed significant complications that required delayed surgery. It seems that patients with limited liver injury diagnosed by CT scan and selected by strictly applied criteria can be managed safely without laparotomy in a setting where rapid evaluation and treatment of any potential complication is available.

Adolescent↗